2025 Great Debates: Every cup deserves a good screw

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Great Debate: To Screw or Not to Screw in Hip Arthroplasty

🎙️ Join host Joe Schwab for the thrilling finale of the AHF podcast's Great Debates series! In this episode, we're diving into the contentious topic of acetabular fixation with Dr. Michael Blankstein and Dr. Nicholas Mast. 💥 Dr. Blankstein argues that every cup deserves a good screw, emphasizing their safety, ease, and crucial role in complex surgeries. Meanwhile, Dr. Mast contends that modern implant designs make screws obsolete, likening their use to reinforcing a sturdy bridge with duct tape. 🤔 Who's right in this orthopedic face-off? Tune in to find out! Don't forget to like, subscribe, and share your thoughts in the comments. 🧠🔧 #AHFPodcast #GreatDebates #AnteriorHipFoundation

Episode Transcript

Joseph M. Schwab (00:00):
Hi, this is Joe Schwab and if you recognize
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(00:24):
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(00:44):
subscriber to the AHF podcast.
Now let's get on with the show.
Hello, and welcome to the AHFpodcast.

(01:07):
I'm your host, Joe Schwab.
Well, welcome to our sixth andfinal great debate where the
topics are serious, thearguments are passionate, and
the innuendo is well kind ofunavoidable.
Today's debate is titled toScrew or Not to Screw, which

(01:28):
means two things.
One.
Yes, this is about acetabularfixation and two, no, there was
absolutely no chance this wasgoing to stay.
PG 13.
Taking the pro position thatevery cup deserves a good screw
is Dr.
Michael Blankstein, who arrivedthe morning of this debate.

(01:50):
Absolutely furious.
I took away his AI generatedslide deck.
Imagine waking up hungover inNashville, Tennessee only to
discover you can't show theworld.
The machine made screw slides.
You were so proud of a tragedy.
Really opposing him is Dr.

(02:11):
Nicholas mast who believesscrews in primary total hip
arthroplasty are basically theorthopedic equivalent of a
rotary phone.
Charming, nostalgic, butunnecessary unless you're
reenacting history.
What follows is a debate aboutfixation stability and bone
biology wrapped in the energy oftwo surgeons who absolutely

(02:35):
knew what they were getting intowith a title like this.
Well buckle up, or I should sayscrew in.
We've got Dr.
Michael Blankstein and Dr.
Nicholas Mast talking aboutevery cup deserves a good screw
In the pro position.

(02:56):
We've got Michael Blankstein.
You get to go first in the conposition.
We've got Dr.
Nicholas Mast.
Gentlemen, keep it clean.
No, don't.

Michael Blankstein (03:06):
Just so you guys know, I went out drinking
last night and I woke up thismorning at 8:00 AM from a text
from Joe Schwab who said, youhave too many slides and I'm,
you only get to use one slide.
And I woke up angry and all Idid is text him why you should
be using slides for this.
'cause I made this AI generateslides that I was so happy about
and I can't use them.
Well, thanks Joe.
So, um, so I just wanna let youknow, an orthopedic surgeon's

(03:30):
best friend is the screw who hastaken an AO course here before.
What's the first lecture youtake?
What's the first thing youlearn about in the AO course?
You learn about the screw.
The Screw is our best friend.
Neil, what's the best feelingyou get during the case when you
do a revision case?
Can you just show me, show me,get up that you know that, that

(03:52):
feeling, the best feeling thatwe experience as surgeons right
there.
How often can one stand up hereand say, guys, what I promote
is safe?
Easy, cheap and quick.
How often, what's exactly whatit is, what's happening here?
When you put a screw in, itliterally takes a couple minutes
For Charlie DeCook, it means 12by 1230 maybe instead of 12 by

(04:18):
12, but literally it's easy.
It's safe.
The anatomy it just so easy.
Now here's the, here's thekicker here.
If you're worried about thesafety of this screw trajectory,
then you should definitelypractice putting in these screws
so you know the anatomy.
So when you need it for yourtough cases, post-traumatic,

(04:38):
dysplastic, osteoporotic, etcetera.
Um, who doesn't like additionalstability?
Now let's talk about thepressfit cup that doesn't get
the screw.
What do you have to do?
You need to rely on good bone.
You need to under ream and headharder.
These are things that you onlyget once in a while.
Who does complex hip surgerieshere?

(04:59):
Most of us, right?
We need those screws.
'cause many of us will do thesecomplex cases.
If you guys wanna quote me, Iwanna be quoted for this for the
rest of my life.
Every screw matters.
It's an opportunity to master,refine, sharpen, and perfect the
technique that is critical forevery hip surgeon.
So my last slide here.

(05:20):
I got one.
You guys.
I would say that you don'talways need a screw, but when
you do, it can save the case.
So you should definitely staysharp, my friends,

Nicholas Mast (05:37):
well to my, uh, esteemed colleague.
Um, I as a man enjoy a goodscrew as much as anybody, but,
um.
The acetabular screw forroutine primaries, the
orthopedic equivalent of a, of arotary phone in the age of
smartphones, um, well considereda necessary crutch in the days

(06:00):
of old, uh, Harris-Galante cups,it was important for stability
of the total hip.
Um, the unquestioned used isless about sound biomechanics,
and more about nostalgia.
It is the orthopedic equivalentof reinforcing a sturdy bridge
with duct tape If theengineering is sound, why do you

(06:21):
need to do that?
Implant designs have advanced,we have high friction coatings.
There's no need for additionalsupplemental fixation.
Uh, it's kind of like clingingto the same decade old scrubs.
A closer look at clinicaloutcomes and surgical risk makes

(06:43):
it clear.
Screws add unnecessarycomplexity, potential
complications.
They make the revision harderand they do not add any
additional longevity to theprosthesis.
But it's understandable that myopponent here continues to
cling to the idea that screwsare necessary.
'cause remember, I believe hetrained in a place where I think

(07:04):
the mullet is still the men's.
Premier fashion.
So I posit to you that the samething in that AO course that
they teach about putting thatfirst screw in.
You learn that from the plate,that every screw hole is an
opportunity, not an obligation.
So thank you.

Joseph M. Schwab (07:26):
One minute rebuttal.

Michael Blankstein (07:29):
I do love that.
Last point.
Good for you again, guys.
Two options.
Get in the cup.
Two minutes put on a screw.
Perfect.
It know what you're doing whenyou need it.
You have that trajectory in theback of your mind.
You know you're threedimensionally oriented.
It's a no brainer.
The alternative is one dayyou're gonna under ream.
One day you're gonna hit toohard.
One day you're gonna have a cupinside the pelvis, and gonna

(07:50):
think I should have listened toDr.
Blankstein.

Joseph M. Schwab (07:54):
One minute rebuttal.

Nicholas Mast (07:57):
Alright, so we're scientists here.
Please show my slide.
So after Joe assigned us ourtopic, a timely paper came out.
And in this paper, theconclusion on a very large
retrospective series showed thatactually in this cohort, the
largest, the longevity, theleast risk of aseptic loosening,
least risk of complications ofthe implant failing were those

(08:21):
without screws.
Thank you.

Joseph M. Schwab (08:24):
Go to your Hova app and vote, and we need
your votes in because we'regonna hand out the awards.
Well, there you have it.
Two seasoned surgeonspassionately debating an issue
that has divided orthopedicssince the dawn of press.
Fitt, whether the humbleacetabular screw is the anchor
of stability or the mullet ofarthroplasty.

(08:47):
Dr.
Blankstein reminded us thatscrews are quick, they're cheap,
they're safe, and bringunparalleled joy, especially if
you learn the craft at an AOcourse where screws are
practically a love language.
Dr.
Mass reminded us that modernday cup designs don't really
need screws, and that adding oneis kind of like putting duct

(09:10):
tape on a well engineered bridgetechnically possible, but.
A bit eyebrow raising andsomewhere in the middle is the
truth.
We all know some cases needthem, some don't, and all of us
have one revision nightmareburned into our memory where the
screw absolutely saved the caseor made the revision twice as

(09:33):
hard.
Thank you for listening to thisfinal episode of the AHF Great
debates.
As always, please take a momentto like and subscribe so we can
keep the lights on and keepsharing great content just like
this.
Please also drop any topicideas or feedback in the

(09:53):
comments below.
You can find the AHF podcast onApple Podcasts, Spotify, or in
any of your favorite podcastapps, as well as in video form
on YouTube slash at anterior hipfoundation.
All one word episodes of theAHF Podcast come out on Fridays.

(10:16):
I'm your host, Joe Schwab,asking you to keep those hips
and screws happy and healthy.